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Single maintenance and reliever therapy (SMART) did not work very well in asthma patients

The use of a combination inhaler containing budesonide and formoterol as both maintenance and quick relief therapy (SMART) has been recommended as an improved method of using inhaled corticosteroid/long-acting beta agonist (ICS/LABA) therapy. Published double-blind trials show that budesonide/formoterol therapy delivered in SMART fashion achieves better asthma outcomes than budesonide monotherapy or lower doses of budesonide/formoterol therapy delivered in constant dosage.

However, it has been reported that only 17% of SMART-treated patients are controlled. In seven trials of 6–12 months duration, patients using SMART:

- used quick reliever daily (average 0.92 inhalations/day)
- awakened with asthma symptoms once every 7–10 days (11.5% of nights)
- suffered asthma symptoms more than half of days (54% of days)
- had a severe exacerbation rate of one in five patients per year (average 0.22 severe exacerbations/patient/year)

These poor outcomes may reflect the recruitment of a skewed patient population.

Although the long-term consequences of SMART therapy have not been studied, its use over 1 year has been associated with significant increases in sputum and biopsy eosinophilia.

At present, there is no evidence that better asthma treatment outcomes can be obtained by moment-to-moment symptom-driven use of ICS/LABA therapy than conventional physician-monitored and adjusted ICS/LABA therapy.

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